Healthcare Provider Details

I. General information

NPI: 1578671830
Provider Name (Legal Business Name): MAZEN DAHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 3RD ST SE STE 200
PUYALLUP WA
98372-3730
US

IV. Provider business mailing address

1420 3RD ST SE STE 200
PUYALLUP WA
98372-3730
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-7660
  • Fax: 253-841-1801
Mailing address:
  • Phone: 253-848-7660
  • Fax: 253-841-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00038984
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: